Role of Hormonal Therapy for Prevention of Osteoporosis in Multiple Sclerosis Patients.

TitleRole of Hormonal Therapy for Prevention of Osteoporosis in Multiple Sclerosis Patients.
Publication TypeJournal Article
AuthorsBishop C, Shilling J, Kraft GH
JournalInternational Journal of MS Care

Individuals with MS are at increased risk for complications of osteoporosis because of decreased mobility, steroid use, and lack of hormone replacement in postmenopausal women. There is an increased risk for falls and fractures. Clinical manifestations include acute fractures, low back or pelvic pain, and posture changes. Inquiries about risk factors alone will miss 70% of women with bone loss. DEXA is the most accurate way to determine bone loss. Bone becomes more porous through loss of normal bone spicules and cross links that provide structure and strength. Bone remodeling has five phases: 1) activation and 2) resorption requiring osteoclasts, 3) reversal and 4) formation requiring osteoblasts, and 5) quiescence. Remodeling is increased by PTH, thyroxine, GH, and vitamin D, and decreased by calcitonin and estrogen. Estrogen helps absorb dietary calcium and magnesium and inhibits osteoclasts, blocking bone breakdown. Progesterone has a modest effect on osteoblasts, stimulating new bone growth. Progesterone exerts its action only if adequate estrogen is present. Testosterone (40 – 60 ng/dL) is an osteoblast stimulator and has greater bone-building effect than progesterone by stimulating new bone growth and enhancing bone strength. Estradiol, progesterone, and testosterone are severely decreased at menopause. Standard dose of horse-derived estrogen does not give adequate levels of estradiol to preserve bone. Estrace is 100% human estradiol. Prevention of bone loss requires estradiol levels above 80 pg/mL. Prevention requires: 1) calcium, magnesium, Vitamin D, 2) weight-bearing exercise, and 3) hormones: estradiol, 0.5-2.0 mg/day; progesterone (Prometrium), 100 mg/day; micronized testosterone, 1.0-4.0 mg/day. The combination of hormones, calcium-magnesium supplements, and exercise has greater bone-protective effect than 1) calcium alone, 2) exercise alone, or 3) exercise and calcium without hormone therapy. Adding testosterone can actually rebuild lost bone density. Cumulative data indicate that management of osteoporosis in postmenopausal women should be incorporated into their care plans.

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